High scored thyroid storm after stomach cancer perforation: A case report

BACKGROUND Thyroid storm is a life-threatening emergency.Reportedly,the prevalence of thyroid storm is 1%-2%among patients admitted to the hospital for thyrotoxicosis.Burch and Wartofsky(1993)introduced a scoring system using precise clinical criteria to identify thyroid storms.Only 17 cases of thyroid storm with a score>70 points have been reported.Although thyroid storms are uncommon,their clinical findings resemble those of sepsis.CASE SUMMARY A 48-year-old man was referred to the emergency room from a local clinic owing to suspicion of gastric ulcer perforation;medications for hypertension,diabetes mellitus,and hyperthyroidism had been suspended 1 year prior to this visit.We performed an emergency distal gastrectomy with Billroth II anastomosis for gastric cardia cancer perforation,and the patient was referred to the surgical intensive care unit(ICU).On the 2nd d in the ICU,his body temperature(BT)increased to 41.3℃ at 19:00,with the thyroid storm score(90 points)peaking at 18:00(BT;41.2℃,pulse rate;138/min,irritable status).The patient was administered propylthiouracil,intravenous glucocorticoids,acetaminophen,and Lugol’s solution daily.Subsequently,we performed bladder irrigation with cold saline using a Foley catheter and applied a hypothermic blanket to decrease the patient's BT.His vital signs were stable on the 8th day in the ICU.CONCLUSION Thyroid storms are uncommon,with few reports in the literature;however,their clinical findings resemble those of sepsis and require further investigation.Since an untreated thyroid storm results in a high mortality rate,it should be investigated when managing sepsis.

Efficacy of probiotics or synbiotics for critically ill adult patients:a systematic review and meta-analysis of randomized controlled trials

Background:Microbial dysbiosis in critically ill patients is a leading cause of mortality and septic complications.Probiotics and synbiotics have emerged as novel therapy on gut microbiota to prevent septic complications.However,current evidence on their effects is conflicting.This work aims to systematically review the impact of probiotics or synbiotics in critically ill adult patients.Methods:A comprehensive search of the PubMed,CBM,Embase,CENTRAL,ISI,and CNKI databases was performed to identify randomized controlled trials that evaluate probiotics or synbiotics in critically ill patients.The quality assessment was based on the modified Jadad’s score scale and the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1.The major outcome measure was mortality.Secondary outcomes included incidence of septic complications,sepsis incidence,length of intensive care unit(ICU)stay,incidence of non-septic complication,and ventilator day.Data synthesis was conduct by Review Manager 5.4.Results:A total of 25 randomized controlled trials reporting on 5049 critically ill patients were included.In the intervention group,2520 participants received probiotics or synbiotics,whereas 2529 participants received standard care or placebo.Pooling data from randomized controlled trials demonstrated a significant reduction in the incidence of ventilator-associated pneumonia(VAP)in the treatment group[(risk ratio(RR)0.86;95%confidence interval(CI):0.78-0.95;p<0.003,I^(2)=85%)].However,in the subgroup analysis,the reduction of incidence of VAP was only significant in patients receiving synbiotics(RR=0.61,95%CI:0.47-0.80,p=0.0004,I^(2)=40%)and not significant in those receiving only probiotics(RR=0.91,95%CI:0.82-1.01,p=0.07,I^(2)=65%).Moreover,sepsis incidence of critically ill patients was only significantly reduced by the addition of synbiotics(RR=0.41;95%CI:0.22-0.72,p=0.005,I^(2)=0%).The incidence of ICU-acquired infections was significantly reduced by the synbiotics therapy(RR=0.72;95%CI:0.58-0.89,p=0.0007,I^(2)=79%).There was no significant difference in mortality,diarrhea,or length of ICU stay between the treatment and control groups.Conclusions:Synbiotics is an effective and safe nutrition therapy in reducing septic complications in critically ill patients.However,in such patients,administration of probiotics alone compared with placebo resulted in no difference in the septic complications.

Mannitol cannot reduce the mortality on acute severe traumatic brain injury (TBI) patients:a meta-analyses and systematic review

Background:We aimed to systematically review the efficacy of mannitol(MTL)on patients with acute severe traumatic brain injury(TBI).Methods:Databases such as PubMed(US National Library of Medicine),CENTRAL(The Cochrane Library 2014,Issue 3),ISI(Web of Science:Science Citation Index Expanded),Chinese Biomedicine Database(CBM),and China Knowledge Resource Integrated Database(CNKI)have been searched for relevant studies published between 1 January 2003 and 1 October 2014.We have established inclusion and exclusion criteria to identify RCTs,which were suitable to be enrolled in the systematic review.The comparison group could be hypertonic saline(HS),hydroxyethyl starch,or others.The quality assessment was based on the Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 and modified Jadad score scale.The major outcome was mortality,followed by the secondary outcomes such as neurological outcome,days on intensive care unit(ICU),and ventilator day.In addition,intracranial pressure(ICP),cerebral perfusion pressure(CPP),and mean arterial pressure(MAP)were used as the surrogate endpoints.Data synthesis and meta-analysis was conducted by using R(version 3.7-0.).Results:When 176 potential relevant literatures and abstracts have been screened,four RCTs met all the inclusion criteria and were enrolled for the meta-analysis.Amongst all the enrolled studies,two trials have provided the primary outcome data.There was no heterogeneity between two studies(I2=0%)and a fixed model was used for meta-analysis(n=53),pooled result indicated that the mortality was similar in mannitol intervention and control treatment,OR=0.80,95%CI[0.27,2.37],P=0.38.We found that both mannitol and HS were efficient in decreasing the ICP.Furthermore,the effect of the HS on the ICP appeared to be more effective in the patients with diffuse brain injuries than mannitol did.Conclusions:As a conclusion,the mannitol therapy cannot reduce the mortality risk of acute severe traumatic brain injury.Current evidence does not support the mannitol as an effective treatment of acute severe traumatic brain injury.The well-designed randomized controlled trials are in urgent need to demonstrate the adoption of mannitol to acute severe traumatic brain injury.

Gut,metabolism and nutritional Support for COVID-19:Experiences from China

There is little research that focuses on the relationship between the gut,metabolism,nutritional support and COVID-19.As a group of Chinese physicians,nutritionists and scientists working on the frontline treating COVID-19 patients,we aim to integrate our experiences and the current clinical evidence to address this pressing issue in this article.Based on our clinical observations and available evidence,we recommend the following practice.Firstly,the Nutritional Risk Screening 2002 tool should be used routinely and periodically;for patients with a score≥3,oral nutritional supplements should be given immediately.Secondly,for patients receiving the antiviral agents lopinavir/ritonavir,gastrointestinal side effects should be monitored for and timely intervention provided.Thirdly,for feeding,the enteral route should be the first choice.In patients undergoing mechanical ventilation,establishing a jejunal route as early as possible can guarantee the feeding target being achieved if gastric dilatation occurs.Fourthly,we suggest a permissive underfeeding strategy for severe/critical patients admitted to the intensive care unit during the first week of admission,with the energy target no more than 20 kcal/kg/day(for those on mechanical ventilation,this target may be lowered to 10–15 kcal/kg/day)and the protein target around 1.0–1.2 g/kg/day.If the inflammatory condition is significantly alleviated,the energy target may be gradually increased to 25–30 kcal/kg/day and the protein target to 1.2–1.5 g/kg/day.Fifthly,supplemental parenteral nutrition should be used with caution.Lastly,omega-3 fatty acids may be used as immunoregulators,intravenous administration of omega-3 fatty emulsion(10 g/day)at an early stage may help to reduce the inflammatory reaction.